One of the most important provider data elements that health plans have to manage is specialty data. It seems there are as many ways to manage provider specialties as there are health plans. Given the critical nature of provider specialty data, health plans need to meet the challenge head-on. A clear approach to collecting and organizing this data is critical. Health plans should assess the contexts in which this data is used to support developing that approach.
Let’s talk about the challenges that managing provider specialty data poses and what can be done about them.
#1 – Multiple Specialty Classification Approaches
The first challenge that a health plan faces is that it may have to report provider data under a variety of specialty lists. These lists can include:
- The National Uniform Claim Committee taxonomy list is used by the NPPES data
- CMS publishes Medicare specialty codes for providers and suppliers eligible to enroll in Medicare with a mapping to taxonomy codes
- CMS HSD tables must be submitted with a specified specialty list
- Many core claims systems come pre-loaded with their specialty taxonomies
- State Medicaid Agencies frequently publish their specialty and provider type lists and crosswalks that Managed Care Organizations must use for encounter and provider reporting
- User-friendly specialty lists intended to provide specialties in layman’s terms (e.g., allowing users to search for a “Heart doctor” and find Cardiologists)
A health plan may be required to report provider information using any or all of these lists for various purposes. This often means creating and maintaining detailed crosswalks between these specialty sets. To further complicate matters, the level of detail in these specialty sets may vary greatly. If a health plan has classified providers using a less specific specialty list, it can be difficult to work backward to get a more granular mapping such as the NUCC taxonomy list.
It is recommended that health plans start with the most granular taxonomy list. That is usually the NUCC list. Once that is done, the plan can create a crosswalk to the less granular lists they need to manage. This crosswalk should allow for more than one detail-level taxonomies to be mapped into a higher-level specialty.
Even with this kind of structure, there will be decisions to be made. This is because the NUCC list is categorized at two levels. This can create a possible conflict when assigning taxonomy codes. This often requires significant research to determine the impact of these mappings on network adequacy and provider access and availability measurements.
Health plans should perform detailed analysis to determine how their providers are distributed across each specialty list. This will support the development of a holistic approach to managing specialty crosswalks.
#2 – Sources of Specialty Information
Health plans can receive information about provider specialty assignments from a variety of sources as well. These can include:
- Roster files from contracted facilities and medical groups
- Provider enrollment forms, either online or paper forms
- The National Plan & Provider Enumeration System (NPPES)
- State Medicaid Agency provider enrollment databases
- Claims data received from non-participating providers
Again, specialties may be reported using several different specialty lists. Health plan staff may have to crosswalk these into an existing list. The data needs to be normalized to fit each context – claims payment, provider directory, and regulatory reporting, among others. Depending on how this is done, it can open the health plan up to introducing incorrect data to claims systems and provider directories.
Whatever the initial source of the specialty information, health plans must perform primary source verification to ensure that it is correct. A provider that is reported to be a cardiologist should have their license verified with the appropriate accreditation agency. Even leveraging a national database like NPPES is not sufficient to accurately credential a provider since the data in NPPES is self-reported.
#3 – Multiple Systems for Managing Provider Data
As provider data is collected and distributed to systems within the plan’s IT ecosystem, it can be very difficult to keep it in sync between all systems. This divergence can be especially evident when it comes to specialty assignments.
Without a well-defined process for managing specialty assignments and crosswalks, errors can be introduced. Health plans may revert to managing this information in spreadsheets. This can introduce versioning and other issues that adversely affect the various consumers of that data.
Health plans should establish a single source of truth for provider data, including specialty assignments. That source of truth should allow the plan to create and manage crosswalks in a centralized location. Further, that source should allow for extracting provider data with the appropriate specialty information for the given context. Separate feeds may go out for claims systems, provider directories, and HEDIS reporting tools.
Impacts of Provider Specialty Data
It’s important to get provider specialty assignments right in all of your systems. Without accurate specialty data, you may experience negative consequences such as:
- Failed CMS provider directory audits
- Corrective Action Plans for failed HSD submissions
- Incorrect claims payments and denials
- Member complaints due to incorrect information
- Network adequacy failures
- Timely access issues
- Increased difficulty in completing timely referrals
Health plans should ensure that they have established best practices for provider data management. This includes establishing a single source of truth. It also includes creating comprehensive specialty crosswalks and managing those centrally. Those crosswalks should be informed by adequate analysis and documented in policies and procedures.
Better Provider Data With Maven One
The Maven One Rules Engine (MORE) allows health plans to follow best practices for provider data management. This includes verifying information against multiple sources, including the NPPES database. MORE Smart Fix technology allows health plans to fix data automatically while maintaining control. Additionally, health plans can create specialty crosswalks that can be used to keep downstream systems accurate and up-to-date.
Find out more about what Maven One can do for your provider data today. Request a customized demonstration using our easy and fast request form.